The essentials for paraoptometric personnel in understanding medical optometry
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The Essentials for Paraoptometric Personnel in Understanding Medical Optometry. Jeff D. Miller, O.D. Stillwater, Oklahoma [email protected] Baby Boomers. Approximately 80 Million 7,918 people turn 60 each day in 2006 That’s 330/hour

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The essentials for paraoptometric personnel in understanding medical optometry

The Essentials for Paraoptometric Personnel in Understanding Medical Optometry

Jeff D. Miller, O.D.

Stillwater, Oklahoma

[email protected]


Baby boomers

Baby Boomers

  • Approximately 80 Million

  • 7,918 people turn 60 each day in 2006

  • That’s 330/hour

  • Every day until 2014, 10,000 Americans turn 50

  • 1/8 Americans are 65 or older


Health of americans

Health of Americans

  • Diabetes –epidemic in children

  • HTN – steep rise

  • CVD – linked w/HTN

  • Obesity – 15% in 1980 - 33% in 2004

  • Obesity doubles the risk of vision loss AMD, Glaucoma, Cataracts, Diabetes


Ocular disease today

Ocular Disease -TODAY

  • Diabetic Retinopathy is the leading cause of blindness ages 25-74

  • AMD is the most common cause of blindness in Americans 60 and older

  • Cataracts are the leading cause of blindness in the world


Ocular disease today1

Ocular Disease-TODAY

  • Glaucoma – 2.2 million cases diagnosed, 2 million undiagnosed

  • 1 Million blind, 2.4 million visually impaired (2/3 are female)

  • By far the most common ocular disorder:

    “Ocular Surface Disease” or OSD


Ocular disease estimates in the year 2020

Ocular Disease EstimatesIn The Year 2020

  • NEI Eye Prevention Research Group

  • Diabetic Retinopathy – 50% increase

  • AMD – 70% increase

  • Glaucoma – 3.36 million – 53% increase

  • Legal Blindness – 70% increase

  • In 2036 all today’s numbers will double


Remember of the eye diseases we are covering today they represent

REMEMBER- OF THE EYE DISEASES WE ARE COVERING TODAY THEY REPRESENT:

A. THE LEADING CAUSE OF BLINDNESS IN THE USA

AGES 25-74.

B. THE LEADING CAUSE OF CENTRAL VISION LOSS IN

PATIENTS OVER 60

C. THE SECOND LEADING CAUSE OF PREVENTABLE

BLINDNESS IN THE USA (CATARACTS ARE FIRST)

AND THERE IS NO WAY TO TELL YOU HAVE THEM BASED ON THE WAY YOU FEEL! THEY ARE ONLY DETECTABLE THROUGH AN EYE HEALTH EVALUATION


Glaucoma

GLAUCOMA

  • Glaucoma is a group of diseases that can damage the eye’s optic nerve and result in irreversible vision loss and blindness.

  • Glaucoma is multifactorial – it is not a single disease process. Rather it is a large group of disorders.

  • The term glaucoma should only be used in reference to the entire group of disorders, just as the term cancer is used to encompass many clinical entities with certain common denominators.


Glaucoma1

GLAUCOMA

  • The common denominator in glaucoma is optic nerve damage/death which derives from various risk factors.

  • Glaucoma is the leading cause of preventable blindness in the US.

  • There are several forms of glaucoma, the most common is Primary Open Angle Glaucoma or POAG.


Forms of glaucoma

Forms of Glaucoma

  • POAG, Primary Open Angle Glaucoma

  • LTG or NTG, Low Tension or Normotensive Glaucoma

  • Angle Closure Glaucoma

  • Congenital Glaucoma

  • Secondary Glaucoma’s – Pigmentary Glaucoma, Neovascular Glaucoma, and Inflammatory or Uveitic Glaucoma, Angle Recession Glaucoma


Risk factors for glaucoma

Risk Factors for Glaucoma

  • Intraocular Pressure, IOP

  • Genetics - Family History

  • Age (increases after 40yrs and 60 yrs)

  • Race (African American, Hispanics)

  • Gender (men or women?)

  • Diabetes Mellitus

  • Cardiovascular Disorders

  • Obstructive Sleep Apnea


Glaucoma diagnosis

Glaucoma Diagnosis

  • Traditionally: IOP, optic nerve changes, visual field defect – treat or monitor.

  • Risk factors are better known today and play a large role in treatment initiation.

  • Today’s technology also allows much earlier diagnosis and treatment initiation through various tests/technology:IOP, stereoscopic optic nerve evaluation, optic nerve topography, nerve fiber layer analysis with scanning lasers and OCT, central corneal thickness, gonioscopy, Visante OCT, blood flow analysis, and visual fields.


Diagnosis

Diagnosis

  • IOP – “normal” 10-22mmHg

  • Remember LTG or NTG, IOP appears

    in the normal range

  • ONH evaluation –characteristic changes

  • CCT - central corneal thickness obtained via pachymetry - normal is 555 microns

  • Gonioscopy – evaluates where the aqueous fluid drains

  • Nerve Fiber layer Analysis: GDx VCC, HRT II and III, OCT (i.e.Stratus,Cirrus)

  • Visual Fields


The essentials for paraoptometric personnel in understanding medical optometry

ONH EVALUATION

Normal Healthy Optic Nerve


The essentials for paraoptometric personnel in understanding medical optometry

Grading cup to disc ratio


The essentials for paraoptometric personnel in understanding medical optometry

Normal Healthy Optic Nerve with small C/D Ratio


The essentials for paraoptometric personnel in understanding medical optometry

SUSPICIOUS ONH


The essentials for paraoptometric personnel in understanding medical optometry

GLAUCOMATOUS


The essentials for paraoptometric personnel in understanding medical optometry

ADVANCED GLAUCOMA WITH OPTIC ATROPHY


The essentials for paraoptometric personnel in understanding medical optometry

ADVANCING GLAUCOMA WITH NOTCHING OF SUPERIOR RIM


The essentials for paraoptometric personnel in understanding medical optometry

EMGTS-patients with exfoliation or recurrent disc hemorrhage may have worse prognosis and need greater tx and closer observation.

CNTGS-”strongly predictive of disease progression”

OHTS-detection of disc hemorrhages-84% were detected only by photos 16% by exam and photos. Increased risk of glaucoma development found however, 86.7% w/disc hem have not converted to glaucoma.


The essentials for paraoptometric personnel in understanding medical optometry

Grading cup to disc ratio


Optic nerve head analysis

Key parameters are Horizontal Integrated Rim Volume* and Cup/Disc ratios

Yellow line on composite diagram indicates individual radial scan selected and displayed

Fundus image for verification of scan placement

Optic Nerve Head Analysis

Disc edge is determined by the end of the RPE -shown by blue marker

*Comparison of three optical coherence tomography scanning areas for detection of glaucomatous damage. Wollstein G, Ishikawa H, Wang J, Beaton SA, Schuman JS. Am J Ophthalmol. 2005 Jan;139(1):39-43


The essentials for paraoptometric personnel in understanding medical optometry

xxx


Cct central corneal thickness

CCT-Central Corneal Thickness

  • Ultrasound Pachymetry (sound waves)

  • Visante OCT Pachymetry (light waves)

  • Ocular Hypertensive Treatment Study

    OHTS – CCT can suggest/determine risk

    >588 microns (low risk)

    =555-588 microns (mod. risk)

    <555 microns (high risk)


Gonioscopy

Gonioscopy


Virtual gonioscopy

Virtual Gonioscopy


The essentials for paraoptometric personnel in understanding medical optometry

Scanning Laser Polarimetry: GDx VCC


Retinal nerve fiber layer

Retinal Nerve Fiber Layer


The essentials for paraoptometric personnel in understanding medical optometry

GDx VCC Printout

Glaucoma

Normal

Fundus Image

Parameters

Thickness Map

Deviation Map

TSNIT Graph

Comparisons of each scan to the Normative Database allows accurate and rapid interpretation in one exam


The essentials for paraoptometric personnel in understanding medical optometry

Correlation of the Deviation Map and Thickness Map with Visual Field Pattern Deviation

is shown below

These are examples from normal to advanced glaucoma

  • A normal eye with normal thickness and deviation maps and normal visual field

  • An eye with focal Retinal Nerve Fiber Layer loss prior to visual field loss

  • A moderate glaucoma eye with superior RNFL loss and inferior visual field loss

  • An advanced glaucoma eye with advanced RNFL and visual field loss


The essentials for paraoptometric personnel in understanding medical optometry

Cirrus™HD-OCT

Stratus OCT™


Glaucoma rnfl thickness analysis

Glaucoma – RNFL Thickness Analysis

An OU analysis example (2)


Visual fields

VISUAL FIELDS

  • Helps to confirm a definitive diagnosis of glaucoma.

  • Determines the degree of vision loss associated with glaucoma.

  • Helps to monitor the progression of the disease and determine treatment strategies and if the medications and/or surgeries are working.


Treatment

Treatment – ultimate goal is to lower IOP by reducing

the production of the fluid in the eye or increasing the

outflow of the fluid (Aqueous)

Medical Treatment

Topical Glaucoma Drops

Various Classes: reduce aqueous production or

increase aqueous outflow

Neuro-protection (now and future)

Blood flow enhancers (future)

Timoptic, Betimol, Betagan, Betoptis S, Azopt, Trusopt Travatan, TravatanZ, Lumigan, Xalatan, Alphagan, Alphagan-P, Cosopt, Combigan, Pilocarpine

What about oral meds ? (Diamox, Neptazane)

Treatment


Surgical treatment

SurgicalTreatment

  • Laser treatment: The laser treats the tissue that the aqueous fluid drains through such that it opens or “cleans” it out increasing drainage ALT - Argon Laser Trabeculoplasty

    SLT - Selective Laser Trabeculoplasty

  • Other Lasers

  • Trabeculectomy - creates drainage canal

  • Glaucoma valve – creates drainage canal


Glaucoma management

Glaucoma Management

  • Once diagnosed patients should be monitored on a quarterly basis for IOP and yearly (at minimum) for changes in VF, optic nerve, nerve fiber layer damage and gonioscopy.

  • The more advanced the more often VF, and other testing should be performed.

  • Glaucoma suspects should be monitored yearly or on a 6 month basis depending on their findings and other health issues.


The essentials for paraoptometric personnel in understanding medical optometry

GLAUCOMA

QUESTIONS ?


Macular degeneration

MACULAR DEGENERATION

  • Leading cause of severe irreversible central vision loss and legal blindness in individuals 60 and older in the US.

  • Predominantly Caucasian (Hispanics on the rise)

  • Approximately 30% of those over 75 have early AMD

  • 23% of the remainder of those will develop it with

    in five years

  • By 2020 the incidence is estimated to rise by 70%

  • By 2036 all today’s numbers will double (Baby Boomers)


Macular degeneration two forms

Macular Degeneration- Two Forms

  • Non-neovascular, dry or atrophic

    macular degeneration

  • Neovascular, wet or exudative

    macular degeneration


Dry or atrophic macular degeneration amd

Dry or Atrophic Macular Degeneration-AMD

  • The retina is 10 layers thick. The last layer is called the RPE - Retinal Pigment Epithelium

  • The RPE is responsible for providing nourishment to the retinal visual cells and maintains the retinal environment

  • If the RPE is sick or damaged the retina degenerates

  • AMD is characterized by abnormalities in the retinal pigment epithelium (RPE) with drusen formation

  • Drusen are tiny white or yellow accumulations in Bruch’s membrane, a membrane between the final layer of the retina (RPE) and its blood supply in the choriocapillaris.


Wet or exudative macular degeneration

Wet or Exudative Macular Degeneration

  • The wet form of AMD is defined by the appearance of “new” blood vessel growth, neovascularization, originating in the layer below the retina called the choricapillaris.

  • These new blood vessels are abnormal and leak fluid and blood into the subretinal space causing disruption of the RPE with subsequent fibrosis and scarring

  • The damage to the RPE is irreversible


The essentials for paraoptometric personnel in understanding medical optometry

Macula


The essentials for paraoptometric personnel in understanding medical optometry

###


The essentials for paraoptometric personnel in understanding medical optometry

RNFL

RGC

Rods & Cones

Retinal Anatomy

RPE


The essentials for paraoptometric personnel in understanding medical optometry

Cirrus HD-OCT Healthy Macula

NFL

ILM

GCL

IPL

INL

OPL

ONL

ELM

IS

IS/OS

OS

RPE

Choroid

NFL: Nerve Fiber LayerOPL: Outer Plexiform Layer IS/OS: Junction of inner and outer

ILM: Inner Limiting MembraneONL: Outer Nuclear Layerphotoreceptor segments

GCL: Ganglion Cell LayerELM: External limiting membraneOS: Photoreceptor Outer Segment

IPL: Inner Plexiform Layer IS: Photoreceptor Inner Segment RPE: Retinal Pigment Epithelium

INL: Inner Nuclear Layer


Diagnosis1

DIAGNOSIS

  • Primarily observation

  • Patients must be seen yearly for eye health exams

  • Retinal evaluation with various lenses and photographic devices

  • OCT/HRT scans (Stratus,Cirrus,HRT-II,III)

  • Fluorescein Angiography (RSFA)

  • Macular pigment optical density


The essentials for paraoptometric personnel in understanding medical optometry

DRUSEN


The essentials for paraoptometric personnel in understanding medical optometry

Drusen and RPE Changes


The essentials for paraoptometric personnel in understanding medical optometry

Drusen and RPE Changes


The essentials for paraoptometric personnel in understanding medical optometry

SOFT DRUSEN


The essentials for paraoptometric personnel in understanding medical optometry

FLOURESCEIN ANGIOGRAPHY- RSFA


The essentials for paraoptometric personnel in understanding medical optometry

xx


The essentials for paraoptometric personnel in understanding medical optometry

DRUSEN


The essentials for paraoptometric personnel in understanding medical optometry

DRUSEN WITH PROGRESSIVE

RPE DISRUPTION/DROPOUT


The essentials for paraoptometric personnel in understanding medical optometry

RSFA OF DRUSEN AND

RPE CHANGES


The essentials for paraoptometric personnel in understanding medical optometry

EXUDATIVE OR WET

MACULAR DEGENERATION


The essentials for paraoptometric personnel in understanding medical optometry

WET AMD


The essentials for paraoptometric personnel in understanding medical optometry

RSFA OF WET

MACULAR DEGENERATION


The essentials for paraoptometric personnel in understanding medical optometry

WET OR EXUDATIVE

MACULAR DEGENERATION


The essentials for paraoptometric personnel in understanding medical optometry

EXTENSIVE WET

MACULAR DEGENERATION


Macular pigment

Macular Pigment


Risk factors

RISK FACTORS

Diets high in antioxidants and lutein have been shown to have a positive effect on controlling the formation and advancement of dry AMD

  • Age

  • Smoking

  • Family History

  • Exposure to UV (sunlight)

  • Females

  • Caucasian

  • Hyperopia

  • HTN

  • Diabetes

  • Cardiovascular Risk Factors

  • High Fat Intake

  • Diets with foods that have a high glycemic index, refined sugars starchy foods “the white stuff”


Atrophic and exudative macular degeneration patient education

Atrophic and ExudativeMacular DegenerationPatient Education

  • The leading cause of blindness in people over 60

  • To avoid: don’t smoke, UV protection, diet high in lutein/antioxidants

  • Carrots vs. broccoli, peas and spinach

  • Dry accounts for 90%, Wet 10%

  • “New abnormal blood vessels” – CNV membranes, grow at a rate of 20 microns/day

  • Wet AMD patients prompted to seek exam when membranes are on avg. 3300 microns


Lutein concentration mcg 100g

Kale 39,550

Turnip Gr. 12,825

Spinach 12,198

Mustard Gr. 9,900

Collard Gr. 8,932

Green Peas 2,477

Brussel Sprouts 1,819

Broccoli 1,403

Yellow corn 764

Asparagus 710

Green Beans 640

Artichokes 464

Red Cabbage 329

Tomatoes 123

White Onion 5

Lutein Concentrationmcg/100g


Injections for exudative amd

Injections for Exudative AMD

  • Block Vascular Endothelial Growth Factor – Anti-VEGF drugs stop the growth of neovascularization in and beneath the retina restoring vision in many cases. Prior to 2005 these drugs were not available and most with wet macular degeneration lost significant vision if laser treatment was not an option.

  • Lucentis $1500 to $ 2500 per injection

  • Avastin $70 to $400 per injection


Amd cataracts and carbohydrate consumption

AMD/Cataracts and Carbohydrate Consumption

  • Carbohydrates – high glycemic index

  • American Journal of Clinical Nutrition – followed 1036 women over 10 years. Carbohydrate intake directly correlated to incidence of early AMD.

  • Dietary glycemic index was also linked with higher incidence of cataracts.


Amd cataracts and carbohydrate consumption1

AMD/Cataracts andCarbohydrate Consumption

  • Annals of Internal Medicine – Study demonstrated women with early AMD were twice as likely to suffer a stroke vs. those who didn’t have AMD.

  • This finding was noted after factoring out smokers, Diabetics, and HTN patients.


The essentials for paraoptometric personnel in understanding medical optometry

MACULAR

DEGENERATION

QUESTIONS ?


Diabetic eye disease

DIABETIC EYE DISEASE

  • DIABETES IS THE LEADING CAUSE OF NEW BLINDNESS IN THE US AGES 25-74.

  • Accounts for 5800 new cases a year of legal blindness.

  • Approximately 25% of diabetics have some degree of retinopathy.

  • A significant increased risk of cataracts and glaucoma is seen in patients with both Type I and Type II diabetes.

  • At minimum, a diabetic should be seen yearly for a full eye health exam.


Diabetic eye disease1

DIABETIC EYE DISEASE

  • The prevalence of retinopathy increases with the duration of diabetes and in those with uncontrolled blood sugar.

  • Patients are usually spared of diabetic retinopathy for

    3-5 years following the onset of the disease.

  • Diabetic retinopathy is broadly classified as nonproliferative and proliferative diabetic retinopathy – NPDR, PDR.

  • NPDR – bleeding and exudates (by-products) present in the retina

  • PDR – the growth of “new and abnormal” blood vessels or neovascularization


Diabetic eye disease2

DIABETIC EYE DISEASE

  • Macular Edema – diabetic cystoid macular edema (DCME) can occur in any stage of retinopathy and results in decreased visual acuity.

  • Retinal treatment other than diet, oral meds and insulin is considered when patients have NPDR with clinically significant DCME to avoid permanent vision loss and progression to PDR


Treatment1

TREATMENT

  • Control of blood sugar is always paramount; daily evaluation as well as regular Hemaglobin A1C.

  • Laser Treatment:

    Macular Grid - for Diabetic Cystoid Macular Edema (DCME)

    Pan-Retinal Laser Photocoagulation –

    or “PRP” to prevent or treat PDR which is characterized by the growth and extension of new blood vessels in the retina and vitreous.


The essentials for paraoptometric personnel in understanding medical optometry

NONPROLIFERATIVE DIABETIC RETINOPATHY - NPDR


The essentials for paraoptometric personnel in understanding medical optometry

NPDR


The essentials for paraoptometric personnel in understanding medical optometry

NPDR


The essentials for paraoptometric personnel in understanding medical optometry

NPDR


The essentials for paraoptometric personnel in understanding medical optometry

NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA AND COTTON WOOL SPOTS (CWS)


The essentials for paraoptometric personnel in understanding medical optometry

PROLIFERATIVE DIABETIC RETINOPATHY


The essentials for paraoptometric personnel in understanding medical optometry

PROLIFERATIVE DIABETIC RETINOPATHY WITH PRE-RETINAL HEMORRHAGE


The essentials for paraoptometric personnel in understanding medical optometry

PROLIFERATIVE DIABETIC RETINOPATHY WITH NEOVASCULARIZATION OF THE DISC

TERMED “NVD”


The essentials for paraoptometric personnel in understanding medical optometry

PDR WITH NEOVASCULARIZATION IN THE RETINA TERMED “NVE” NEOVASCULARIZATION ELSEWHERE


The essentials for paraoptometric personnel in understanding medical optometry

PAN-RETINAL PHOTOCOAGULATION

“PRP”


The essentials for paraoptometric personnel in understanding medical optometry

RETINAL FIBROSIS


The essentials for paraoptometric personnel in understanding medical optometry

RETINAL FIBROSIS


The essentials for paraoptometric personnel in understanding medical optometry

RETINAL FIBROSIS WITH SUBSEQUENT RETINAL DETACHMENT


The essentials for paraoptometric personnel in understanding medical optometry

RETINAL DETACHMENT


Patient management

PATIENT MANAGEMENT

  • Diabetics should be examined yearly at minimum.

  • Visit schedule should be adjusted when patients are suspect for progression of retinopathy and or Diabetic Cystoid Macular Edema (DCME).

  • Photodocumentation, IOP checks, retinal imaging (OCT, HRT), and gonioscopy should all be considered based on the patients clinical presentation.

  • Education should include other ocular complications; glaucoma and cataracts.


The essentials for paraoptometric personnel in understanding medical optometry

DIABETIC EYE DISEASE

QUESTIONS ?


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